A 70-year-old client in a nursing home is found wandering in the hall and has a new onset confusion. Which action should the registered nurse implement ́ first?
Notify the client's family to come visit client
Instruct the client return to their room
Ask the unlicensed assistive personnel (UAP) to push fluids
Assess the client's lung fields and temperature
The Correct Answer is D
A. Notifying the client's family may be appropriate after assessing the client and identifying the cause of the confusion. However, it is not the first action, as the priority is to determine if the confusion is due to a medical condition requiring immediate attention.
B. Instructing the client to return to their room addresses the wandering behavior but does not address the underlying cause of the new onset confusion. Without further assessment, this action may delay necessary interventions.
C. Asking the UAP to push fluids assumes that dehydration is the cause of the confusion without evidence. While encouraging hydration may be beneficial later, it is essential first to assess for other potential causes, such as infection or hypoxia.
D. Assessing the client's lung fields and temperature is the first priority because new onset confusion in an older adult is often a symptom of an underlying medical issue, such as infection (e.g., pneumonia or urinary tract infection) or hypoxia. Early assessment helps identify the cause and guide appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tidal fluctuation in the water seal chamber is an expected finding in a chest tube drainage system. It indicates that the pleural space is still connected to the atmosphere, and the lungs are expanding and contracting normally.
B. Continuous bubbling in the suction control chamber is normal when the chest tube is connected to suction. This shows that the suction system is functioning properly.
C. Chest tube eyelets not being visible is expected when the chest tube is properly positioned inside the pleural space. This finding does not require immediate notification.
D. Development of subcutaneous emphysema (air trapped under the skin) may indicate an air leak or improper chest tube placement. This finding requires immediate notification of the provider to address the underlying cause and prevent complications.
Correct Answer is ["31"]
Explanation
- Convert liters to milliliters: 1 liter = 1000 mL
- Calculate total infusion time in minutes: 8 hours 60 minutes/hour = 480 minutes
- Apply the formula:
- (Total volume in mL Drop factor) / Total infusion time in minutes = Drops/minute
- (1000 mL 15 gtts/mL) / 480 minutes = 31.25 gtts/minute
- Round to the nearest whole number: 31 gtts/minute
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